This is an explanation of the purpose of the form ...
Please provide your/the nomination source contact information: * indicates required information.
First Name Last Name Title Organization Street Address Address (cont.) City State/Province Zip/Postal Code Country Home Phone FAX E-mail URL
Please provide the following contact information for the award nominee. * indicates required information.
For which award are you nominating the candidate?
Ulrichs Community Contribution Award Eleanor Community Leadership Award Mother Courage Community Support Award
What are your reasons for nominating this candidate for the specified award? Please be specific.
Please describe in detail the actions of the nominee with regard to the specified award which in your feelings qualify the receipt of an award.
Please choose the level of the award for which you are nominating.
City/Town/Rural State Country
Please provide the names and email addresses of the appropriate second nomination sources for this nomination. City-Town-Rural-3, State-6, Country-12
By my electronically singing this form I am stating that the contacts listed for me are active and that the statements made by me in nomination of an award candidate are factual to the best of my knowledge.